Part I: Safe Motherhood
Kristen Cotter, MSIV
Africa: % of all Maternal
Death: 48% Lifetime risk: 1 in 20 MMR: 830
Developed Countries: % of all Maternal
Death: 0.5% Lifetime risk: 1 in 2500 MMR: 20 (per 100,000 live births)
WHO/UNICEF/UNFPA, 2000
Why care (and act)?
529,000 maternal deaths in 2000 Often leading cause of adult female death Great disparity
– MMR 50x higher in developing countries
Infant health & survival affected Maternal deaths are avoidable
Causes of Maternal Death Worldwide
20%
8%
7%
13%
13%
15%
25%
Indirect
Other direct
Obstructed labor
Unsafe abortion
Eclampsia
Sepsis
Hemorrhage
Note: #1 cause of Maternal Death in USA doesn’t even make the top 5.
The Making Pregnancy Safer Initiative(Safe Motherhood Initiative)
Vision: All women go safely through pregnancy and childbirth, and that their infants are born alive and healthy.
Goal: To reduce maternal mortality by 75% from 1990 levels by the year 2015.
www.WHO.org
The old hope (1987 Nairobi S.M. Conference). . .
The key to reducing maternal mortality was in the community– Risk assessment by trained non-doctor
Low risk delivery with TBA High risk referred to skilled attendant
– Antenatal care by TBAs
New realizations (1997 Columbo Technical Consultation). . .
Every pregnancy faces risk No data to show that training TBAs lower MM Key to lowering MM: Health Infrastructure
Clean, Safe Delivery
with Skilled Attendance
for all women
Key Components of Safe Motherhood
Skilled attendance (now 62%) Health systems
– Policies– Essential supplies of medicines and equipment– Infrastructure– Referral system– Monitoring & evaluation– Supervision & training of staff– Records
Involving communities
Part II: Safe Motherhood Needs Assessment
Kikoneni and Dzombo Locations
Kwale District, Coast Province,
Kenya
Kristen Cotter
March – May 2003
ICRH Background
Branch of Univ. of Ghent SOM,
Dept. of OB/Gyn Kenya programs include:
– HIV prevention (sex workers, workplace, youth)– Voluntary Counseling & Testing (VCT)– Prevention of Mother-to-Child Transmission of
HIV– Safe Motherhood
Kikoneni and Dzombo LocationsBackground
Pop. 44,647 2 hours outside of Mombasa Estimated HIV seroprevalence: 9% 49% ♀, 29% ♂ never attended school 8% ♀, 17% ♂ educated past primary school Home building materials:
– Grass/palm roofs 74%– Mud and wood walls 64%– Earth floors 75%
Kenya Background
MMR: 1000 per 100,000 live births Lifetime risk of OB death: 1 in 19 Fertility rate: 4.7
– Rural: 5.2– No education: 5.8
♀ using modern contraception: 32% Births in health facility: 42%
(WHO/UNICEF/UNFPA 2000, DHS 1998)
Design and Methodology
Survey tools developed and used in similar settings– MEASURE Evaluation– WHO Safe Motherhood Needs Assessment
Adapted by ICRH staff Professionally translated & back-translated into Swahili Locations
– Kikoneni Health Centre (KHC)– 3 Dispensaries– Mobile Clinic
Interviewer: Diana Ngombo (clinical & PH nurse, ICRH staff)
Overview of Assessment
Retrospective Review of KHC clinical records– ANC Register– FP Register– Maternity Admissions Register
Cross-Sectional Surveys– Facilities Assessment (drugs, equip., supplies)– Human Resources (provider knowledge, training)– ANC Client Exit Interviews– TBA Interviews
Limitations
Sample sizes small Multiple translations Non-random sampling
– ANC clients in register, but only 12-22% had lab results recorded– Women who come to clinics for ANC or delivery are different from
general community
Descriptive only. Cannot be generalized. Without community-wide survey, prevalence cannot be
determined (though we tried) Observation bias & social desirability bias Population Council tool problematic
WHO Pillars of Safe Motherhood
Pillar #1 ANC Pillar #2 Clean, safe delivery Pillar #3 Emergency Obstet. Care Pillar #4 Family Planning
Pillar #1: Antenatal CareReview of ANC Register
New ANC clients at KHC 44 pt/mo Age 22.4 yrs Parity 2.0 children Age of nulliparous pts 18.6 yrs Adolescent pts 33% Gestational age at presentation 26 wks
– 3rd trimester 45%
Previous children dead 12%
Pillar #1: Antenatal CareReview of ANC Register
Lab results Anemia (Hb<10.0) 92%
– Mild (Hb 8.1-9.9) 32%– Moderate (Hb 5.1-8.0) 57%– Severe (Hb <5.0) 2%
Syphilis 2% Malaria 9% Helminths 38% Schistosomiasis 5% Negative Rhesus 3%
Pillar #1: Antenatal CareHC Provider Management
Iron “all”– Non-Anemic: 200 mg tid for 1 week– Anemic: 200 mg tid for 1 or 2 weeks– Referral at Hb ≤5.0– Barriers: stock shortages, cost
Folate “all”– 5 mg tab for 1 week– Stock shortages, cost
Pillar #1: Antenatal CareHC Provider Management
Multi-Vitamins “some”– 1 tab bid or tid for 1 week
SP (Sulphadozine Pyrimethamine) “all”– 3 tab stat, twice during pregnancy
Deworming “all,” “some”
Pillar #1: Antenatal CareCost of 1st ANC visit
Service/Supplies KShConsultation + labs 160ANC card 20Iron x 2 weeks 20Folate x 2 weeks 20Vitamins x 2 weeks 20Ketrex 20SP FreeTetanus toxoid FreeTetanus (syringe) 10__________Total KSh 270 (= US$3.50)
(26% of Kenyans live below $1 per day)
Pillar #1: Antenatal CareANC Exit Interview, KHC
KHC Mobile Transportation Walked 80% 83% Time 66 min. 66 min.
Client-Provider Meeting time 14 min. 7 min. Advised to return 94% 100%
Pillar #1: Antenatal CareANC Exit Interview, KHC
KHC MobilePhysical Exam Abdominal exam 100% 100% Fetal heart beat 100% 100% BP check 97% 100%Medical Hx 100% 100%Medications SP 97% 50% Iron 91% 42%Investigations Blood 69% 13% Urine 69% 13%
Pillar #1: Antenatal CareANC Exit Interview, KHC
Counseling Topic KHC MobileBirth plan (place) 17% 0Benefits of delivering in a health facility 9% 0Nutrition Counseling 6% 8%FP or child-spacing 3% 13%STIs, HIV, AIDS 3% 33%Transportation in event of emergency 3% 0Action if bleeding or seizures 0 0Infant care 0 8%
Pillar #2: Clean safe delivery
Safe Attendance =
Trained attendant+
Enabling environment
(Equipment, Drugs, Facilities)
Pillar #2: Clean safe deliveryBasic OB Equipment
All 4 All 4 3/4Sphygmo- Delivery set Scrub basin manometer IV fluid sets Suture set Stethoscope Sponge forceps Suturing trayGloves Forceps bowl ContainersNeedles & receiver Stretchers & syringes Vaginal speculum
Adult scales Suture needles & materialsBaby scales Thermometer Fetal stethoscope Padded tongue bladeExamination table
Pillar #2: Clean safe deliveryBasic OB Equipment
2/4 1/4 0/4IV catheter sets Tourniquets AmnihookStopwatch/Watch Straight Catheter Foley catheterSterilizer Partographs Nitrazine paperAntenatal forms Centrifuge or Sterile packing Tape measure hemoglobinometer material
Urine testing Towels or cloth equipment Oxygen tank
Sterile 4x4 gauze MVA Vacuum extractorProtective gown Bulb syringe
Pillar #2: Clean safe deliveryBasic OB Equipment
KHC equipment scores Absolute Minimal for Delivery 1.00 Basic Equipment 0.67 Partographs 1.00 ANC 1.00 APH 1.00 Eclampsia 1.00 Infection 1.00
Pillar #2: Clean safe deliveryBasic OB Equipment
KHC equipment scores (con’t) Complicated Deliveries
& Lacerations 0.73 Dysfunctional Labor 0.60 PPH 0.50 Normal L&D 0.44 Storage 0.00
Pillar #2: Clean safe deliveryMedication
Normal L&D 1.00 ANC 0.50 Dysfunctional Labor 0.50 Complicated Deliveries & Lacerations 0.33 PPH 0.33 Infection 0.33 APH 0.00 Eclampsia 0.00
Pillar #2: Clean safe deliveryFacilities
Water– KHC: rainwater & borehole pump– Dry sinks & showers & toilets
Electricity– generator house, but no generator
Pillar #2: Clean safe deliveryAttendant knowledge
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
perform menstrual extractions
check hemoglobin
suture (repair) cervical lacerations
perform internal versions
perform prenatal risk screening
bimanually compress the uterus (internal)
suture (repair) 3rd/4th degree lacerations
perform reflex testing
perform external versions
perform vacuum extractions
bimanually compress the uterus (external)
use partographs to manage labor
first assist at C/Section
manually remove placentas
start IV infusions
suture (repair) episiotomies
suture (repair) vaginal lacerations
perform speculum examinations
perform bimanual examinations
Skill
Percent
Pillar #2: Clean safe deliveryCoverage
Kenya (DHS 1998) 42% 31 KHC births ÷
659 expected births (K’neni Loc)= 5% 74 KHC births ÷ 994 ANC clients (KHC)= 7% ANC clients reporting last birth in health facility
– Mobile Clinic (1 of 14) 7%– KHC (12 of 29) 41%
Limitations!– Other birthing facilities?– ANC clients are not a random sample!
Pillar #2: Clean safe deliveryPreference & Demand
Final decision-maker if referral needed– Husband 100%
Why women choose TBAs instead of health facility (according to TBAs)– Can deliver at home85%– Cheaper/free 31%– Natural to them 8%
Pillar #2: Clean safe deliveryTraditional Birth Attendants
Married women with >4 children 60% never went to school 3.2 deliveries per month (0.9 last month) Most have other primary occupations Learn by apprenticeship (“gift from God” or goats) 4 of 13 had attended training Herbal medicines & spiritual practices included
– Also provided for men and non-pregnant women
Pillar #2: Clean safe deliveryTraditional Birth Attendants
Equipment: 54% razors
46% gloves
39% soap
ANC PE: 82% assess baby’s position Delivery prep: 62% sterilize equipment
54% wash hands
Eating/drinking encouraged during labor
Pillar #2: Clean safe deliveryTraditional Birth Attendants
When bear down?– Woman feels urge to push 85%– Excessive pain/screaming 54%– Water breaks 46%– Urge to defecate 39%– Crowning 23%
Pillar #2: Clean safe deliveryTraditional Birth Attendants
Sometimes insert hand into vagina39% Episiotomies 0 Perineal tears 31%
– Tx: warm saline baths/compresses Manual version for malpresentation 54% Razors to cut cord 100%
– Boil 70%– Wash 31%
Pillar #2: Clean safe deliveryTraditional Birth Attendants
How to make placenta come out– Press on abdomen 69%– Wait 31%– Beaded necklace 15%
Pillar #3: Emergency Obstetric Care
Attendant knowledge– Clinical case scenarios
“ANC pt at 32 wks gestation, c/o swollen hands & feet and increased HAs”
“Pt c/o malaise 48 hrs after delivery”
– History-taking– Physical Exam– Action
Pillar #3: Emergency OB CareAttendant knowledge
0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00
APH Action
Infection Action
PPH Action
PPH Identification
Dysfunctional Labor Identification
Eclampsia Action
Infection Ask
APH Identification
Infection Follow Up
PIH Action
PPH Urgent Action
Kn
ow
led
ge
ca
teg
ory
Calculated score
Pillar #3: Emergency OB CareReferral System
Transportation– No formal system– Family arranges matatu or car
KSh 2000
– 2+ hrs from referral to hospital– Dispensaries refer directly to Msambweni
Pillar #4: Family PlanningFP Register, KHC
Fertility– Kenya TFR (DHS 1998) 4.7– Mean parity of ANC pts (Register) 2.0– Mean gravida of ANC pts (Exit) 3.7 & 3.4– TBAs 5.7 children
Counseling opportunities– 3% of ANC pts at KHC (Exit)– 13% of ANC pts at MC (Exit)– 15% of PNC pts for TBAs (TBA)
Pillar #4: Family PlanningFP Register, KHC
Attendance: 96.7 visits/month
0
50
100
150
200
250
300
350
400
2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 2002-Q4
nu
mb
er
of
cli
en
ts
Unspecified
Return
New
Pillar #4: Family PlanningFP Register, KHC
Last birth in health facility: 41.4%Last birth in health facility: 41.4%
0.00
20.00
40.00
60.00
80.00
100.00
120.00
Q1 2001 Q2 2001 Q3 2001 Q4 2001 Q1 2002 Q2 2002 Q3 2002 Q4 2002
Quarter
CY
P p
rov
ide
d
Norplant
Condom
OCP
Depo
Couple Years of Protection: with Norplant
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Q1 2001 Q2 2001 Q3 2001 Q4 2001 Q1 2002 Q2 2002 Q3 2002 Q4 2002
Quarter
Pe
rce
nta
ge
of
dis
trib
uti
on
ev
en
ts
Norplant
Condom
OCP
Depo
Pillar #4: Family PlanningFP Register, KHC
Distribution Events: Depo Condoms
Pillar #4: Family PlanningFP Register, KHC
Coverage Female pop. of Kikoneni Location: 7533 Females of Reproductive Age: ~5,251 FP visits: 2321 for 2001-2002 0.22 visits per Female of Repro Age Ratio of 1 visit per 4.55 women
Limitation: Not a community-wide survey
Conclusions: Pillar #1 Antenatal Care
Med Hx, PE, ANC cards, & adequate time with provider offered to nearly all ANC clients
Lab coverage is low: 69% KHC, 12.5% MC Coverage of SP for IPT: 97% KHC, 50% MC Anemia: 92% Helminths: 38% Minimal counseling, including STIs/HIV Late gestational age at presentation for ANC HIV testing & PMTCT not yet available
Conclusions: Pillar #2 Clean Safe Delivery
67 women have delivered at KHC since 2001= 7.4% of ANC clients at KHC= 5.3% of expected births for Kikoneni LocationKenya MOH goal for 2010: 80% births with skilled attendance
KHC is well equipped and staff well trained to provide normal delivery services.
No water & electricity at KHC, though infrastructure in place
Few deliveries at dispensaries
Summary of Pillar #3Emergency Obstetric Care
KHC referred 9.5% of maternity pts Referrals from dispensaries are rare. Few/no
complications seen in last year. Pre-referral management of complications score
poorly If KHC is to provide “basic OB care,” more
equipment & drugs are needed Transportation: 1.5 to 3.0 hours from referral to
arrival at hospital
Summary of Pillar #4:Family Planning
97 visits per month at KHC Norplant’s addition to MM raised CYP
substantially Condom distribution is low ANC clients counseled on FP during
pregnancy: 3% KHC, 13% MC 15% of TBAs provide FP advice during PNC
Recommendations
Policy considerations– Iron dosing, transportation, Rh- referrals, PNC. . .
Quality of Female Reproductive Health Care– Labs, delivery, ed., condoms. . .
Staff Training and Development Community-based Opportunities
– Gender, empowerment, men, delayed marriage. .
Questions? Responses?
Part III: Parting thoughts on INHL
How I squeezed INHL into med school
Summer between 1st and 2nd year– Spanish language school
IHMEC conference in Honduras CAMC Family Medicine in Honduras MPH (“year off”), with internship in Kenya 4th year elective in Paraguay
Opportunities & Resources
www.ihmec.org– International Health Medical Education Consortium– Links to hundreds of INHL organizations, rotations, volunteer-
seeking groups, etc.– Join!
http://nhsc.bhpr.hrsa.gov/ambassadors/training-abroad.cfm
– Spanish language learning and serving opportunities http://www.aamc.org/students/medstudents/
overseasfellowship/ – Fellowship for 1 year of mentored clinical research in developing
countries, for graduate students in health sciences
MPH Programs
Strong INHL programs– Harvard– Johns Hopkins– UNC Chapel Hill– Tulane University
Usually 1 year with MD
Things to Read
Mountains beyond Mountains, The Quest of Dr. Paul Farmer, a man who would cure the world, 2003, by Tracy Kidder
Alma Ata Declaration, 1978
Thank you!